Teaching Physician Attestation

Professional Component

November 2014

Teaching Physician Attestation

If a resident participates in a visit

(Evaluation and Management services-

outpatient and/or inpatient), the teaching physician needs to be present during the visit with the patient. The resident should mention the teaching physician's name in

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his/her documentation. The teaching

physician should mention the residents

name in his/her attestation. The resident may document all the elements of the visit (History,

Examination, and Medical Decision Making). However, in order for the teaching physician to be able

to bill for this visit, he/she needs to personally add an attestation to the resident's note.

The following are examples of acceptable Teaching Physician's Attestation:

"I performed a history and physical examination of the patient and discussed management plan with

the resident

". I reviewed the resident's note and agree with the documented findings

and plan of care".

"I saw and examined the patient and agree with the resident the heart murmur is louder, so I will obtain an echo to evaluate".

documentation, except

"I saw and evaluated the patient. I reviewed the resident

note and agree, except

that the picture is more consistent with pericarditis, than myocardial ischemia. Will begin NSAIDs".

"I saw and evaluated the patient. Agree with the resident are weaker, now 3/5; MRI of L/S spine today".

note but lower extremities

More information is available at the Office of Billing Compliance website.

Medicare Rule For Teaching Physicians

PHYSICIAN'S VERIFICATION OF PRESENCE, WHERE A SURGICAL PROCEDURE IS PERFORMED, IN THE UMCARE SYSTEM, IS REQUIRED IN ORDER TO COMPLY WITH THE MEDICARE RULE FOR TEACHING PHYSICIANS.

Split/Shared Visits with Non-Physician Practitioners (NPP)

Shared visits are evaluation and management (E/M) services provided to the hospital inpatients or outpatients. These services are literally "shared" between the physician and a NPP. If both the physician and the NPP have a face-to-face encounter with the patient, the service can be billed under the physician's provider number and is reimbursed at 100 percent of the Medicare fee schedule, or under the NPP provider number and is reimbursed at 85% of Medicare fee schedule.

For a shared visit, the physician would provide and document some of the (visit) E/M service and the NPP would provide and document some of the (visit) E/M service.

It is not sufficient for the physician to document, "Seen and agree," nor is it sufficient to simply countersign the NPP note.

In addition, documentation of an attestation such as the one a physician would use with a resident/fellow is not applicable. The Medicare Rule for Teaching Physicians does not apply to NPPs.

The physician may see the patient before, after or at the same time the NPP sees the patient. The NPP may document the bulk of the note, but the physician must specifically document the elements of the visits he or she has personally performed.

Prepayment Review for Initial and Subsequent Hospital Evaluation and Management Services CPT? codes 99223 and 99233

Florida's Medicare Carrier, First Coast Service Options Inc. (First Coast) recently conducted data analysis due to the high Comprehensive Error Rate Testing (CERT) error rates for evaluation and management services pertaining to CPT? codes 99223 (initial hospital visit) and 99233 (subsequent hospital visit). The data indicates that the specialty of Internal Medicine is the primary contributor to the CERT error rate: Internal Medicine error rates are currently trending at 36.6 percent for CPT? code 99233 and 33.3 percent for CPT code 99223.

In response to the high percentage of error rates associated with hospital visits billed by Internal Medicine physicians, First Coast implemented a prepayment medical review audit effective October 21, 2014.

2015 Changes For Anesthesiology

In 2015 the following three codes have been deleted:

00452 - Anesthesia for procedures on clavicle and scapula; radical surgery 00622 - Anesthesia for procedures on thoracic spine and cord; thoracolumbar sympathectomy 00634 - Anesthesia for procedures in lumbar region; chemonucleolysis. New TAP Block Codes

Physicians sometimes use transverses abdominis plane (TAP) catheters as an alternative to epidural analgesia after upper abdominal surgery or as an adjunct to anesthesia during an abdominal laparoscopic procedure. CPT? currently doesn't include a code specifically for a TAP catheter, so that service is billed using code 64999 (Unlisted procedure, nervous system) and a copy of the procedure report is submitted.

In 2015, there will be four new codes that differentiate between injection and continuous infusion, and whether the physician administer a unilateral or bilateral injection(s). The following procedure codes will replace code 64999.

64486 - Transversus abdominis plane (TAP) block (abdominal plane block, rectus sheath block) unilateral; by injection(s) (includes imaging guidance, when performed) 64487 - ... by continuous infusion(s) (includes imaging guidance, when performed) 64488 - Transversus abdominis plane (TAP) block (abdominal plane block, rectus sheath block) bilateral; by injections (includes imaging guidance, when performed) 64489 - ... by continuous infusions (includes imaging guidance, when performed).

2015 Changes For Ob/Gyn

Question: When we report global Ob Care, it includes a "postpartum exam?" What is the definition of the post-partum exam?

Answer: The postpartum exam is any routine care the Ob-Gyn normally provides after the birth of the baby. This exam occurs within the six-week standard time frame for a Vaginal Delivery or eightweek period for Cesarean Delivery. Complications during the postpartum period could be billed separately, however routine checks, no matter how many there are, are included.

The American Congress of Obstetricians and Gynecologists' guidelines for perinatal care recommends that about four to six weeks after delivery, the mother should visit her physician for a postpartum review and examination. "This interval may be modified according to the needs of the patient with medical, obstetric, or intercurrent complications. A visit within 7-14 days of delivery may be advisable after a Cesarean Delivery or a complicated gestation,"

The review during the postpartum visit should include:

history physical examination to evaluate the patient's current status evaluation of her adaptation to the newborn specific inquiries regarding breastfeeding assessment of weight, blood pressure, breasts and abdomen, as well as a pelvic examination evaluation of episiotomy repair and uterine involution a Pap test, if needed review or initiation of birth control counseling for preconception if the patient intends to have future pregnancies.

The ACOG guidelines indicate that the global service includes, among other things, uncomplicated outpatient visits until six weeks postpartum. Some payers use six weeks as the standard, this may vary based on payer.

2015 Changes For Ophthalmology

CCI Edits introduces a number of new edits involving a temporary Category III CPT? code, 0356T (Insertion of drug-eluting implant [including punctual dilation and implant removal when performed] into lacrimal canaliculus, each). The code, part of Category III, which describes new and emerging technology, was introduced effective July 1, 2014.

The code describes the insertion (and removal, when performed) of implants designed to help reduce postoperative inflammation and pain, as well as reduce of intraocular pressure in patients with glaucoma or ocular hypertension.

Effective Oct. 1, CCI has bundled these codes into 0356T:

67500 - Retrobulbar injection; medication (separate procedure, does not include supply of medication) 68440 - Snip incision of lacrimal punctum 68530 - Removal of foreign body or dacryolith, lacrimal passages 68700 - Plastic repair of canaliculi 68770 - Closure of lacrimal fistula (separate procedure) 68801 - Dilation of lacrimal punctum, with or without irrigation 68810 - Probing of nasolacrimal duct, with or without irrigation 68811 - ... requiring general anesthesia 68815 - ... with insertion of tube or stent 68816 - ...with transluminal balloon catheter dilation 68840 - Probing of lacrimal canaliculi, with or without irrigation.

2015 Changes For Otolaryngology and Gastroenterology

Effective January 1, 2015, CPT? is adding a new code 43180, Esophagoscopy, rigid, transoral with diverticulectomy of hypopharynx or cervical esophagus [eg, Zenker's diverticulum], with cricopharyngealmyotomy that includes the use of telescope or operating microscope and repair. This code will allow gastroenterologists or other specialists to identify the emerging procedure for nonsurgical and non-incisive removal and repair of Zenker's diverticulum, endoscopic cricopharyngealmyotomy, transoral repair of Zenker's diverticulum.

2015 Changes For Orthopaedic

Sacroplasty: For Sacral Vertebroplasty the following two Category III codes will include imaging guidance:

0200T - Percutaneous sacral augmentation (sacroplasty), unilateral injection(s), including the use of a balloon or mechanical device, when used, 1 or more needles, includes imaging guidance and bone biopsy, when performed 0201T - Percutaneous sacral augmentation (sacroplasty), bilateral injections, including the use of a balloon or mechanical device, when used, 2 or more needles, includes imaging guidance and bone biopsy, when performed. Arthroplasty: Total Disc Arthroplasty codes now include a second level cervical placement. The revised and new codes are as follows:

22856 - Total Disc Arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection), single interspace, cervical; single interspace, cervical 22858 - ... second level, cervical (List separately in addition to code for primary procedure). Two Category III codes for Arthroplasty procedures:

0375T - Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection), cervical, three or more levels 0376T - ... each additional device insertion (List separately in addition to code for primary procedure) Arthrodesis: The new codes for Arthrodesis procedures, are:

27279 - Arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft when performed, and placement of transfixing device

The following is a revised Sacroiliac Joint Arthrodesis code, 27280 - Arthrodesis, open, sacroiliac joint (, including obtaining bone graft), including instrumentation, when performed

Contrast injection: The following new code is for knee arthrography:

27370 - Injection procedure of contrast for knee arthrography

2015 Changes For Pain Management/Orthopaedics/Radiology

Kyphoplasty, Vertebroplasty Code Overhaul

Billing for Kyphoplasty and Percutaneous Vertebroplasty services will change in 2015. The following six new codes, that will represent the services based on the number of vertebral bodies and the spinal area treated, will be in effect:

Codes currently in effect such as 22520-22525, will be replaced with the following ones:

22510 - Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; cervicothoracic 22511 - ... lumbosacral +22512 - ... each additional cervicothoracic or lumbosacral vertebral body (List separately in addition to code for primary procedure) 22513 - Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; thoracic 22514 - ... lumbar +22515 - ... each additional thoracic or lumbar vertebral body (List separately in addition to code for primary procedure). Important: Note that Each code will continue to represent both unilateral and bilateral injections.

The biggest change is the addition of "inclusive of all imaging guidance" to the descriptors. Each of the new codes also includes the "bulls-eye" symbol designation, which means the associated RVUs and service include moderate sedation. This is new for Kyphoplasty in 2015. he 2014 codes (2252322525) did not include moderate sedation, so you could bill it separately.

The new Vertebroplasty code, 22510, will also include the cervical spine region.

Because of the updated descriptors, the associated radiology codes for guidance will be deleted. We no longer be able to bill the following codes as part of your Vertebroplasty or Kyphoplasty services:

72291 ? Radiological supervision and interpretation, percutaneous vertebroplasty, vertebral augmentation, or sacral augmentation (sacroplasty), including cavity creation, per vertebral body or sacrum; under fluoroscopic guidance 72292 ? ... under CT guidance.

2015 Changes For Radiology Check Bone Density Study with Vertebral Fracture Assessment

76641 - Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete 76642 - Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; limited Also add the following three codes for breast tomosynthesis:

77061 - Digital breast tomosynthesis; unilateral 77062 - Digital breast tomosynthesis; bilateral 77063 - Screening digital breast tomosynthesis, bilateral (List separately in addition to code for primary procedure) New Codes for Breast Ultrasound and Digital Tomosynthesis

Effective 2015, code 77082 (Dual-energy X-ray absorptiometry (DXA), Bone Density Study, one or more sites) for vertebral fracture assessment, will no longer be valid. This code will be replaced with two new codes for vertebral fracture assessment.

2015 Changes For Pathology

The College of American Pathologists (CAP) estimates overall payment to pathologists will increase 1%, Independent Laboratories will see a 3% increase compared to 2014. The CAP's impact table can be found here.

Surgery Global Periods Medicare Proposed Changes 2017 & 2018

Perhaps the most radical change proposed by Medicare is the elimination of 10- and 90-day global periods. The proposal recommends phasing in the changes, with 10-day global procedures moving to 0day global procedures, beginning in 2017, and 90-day global procedures moving to 0-day global procedures beginning in 2018.

This payment scheme, would allow billing for preoperative and postoperative care and other services provided, whether related or unrelated, without modifiers or additional payment reductions. Additionally, coordination of care among providers, where surgery is provided by one physician or group, and follow-up care provided by others, will not also be required.

With the postponed elimination of the global period, Medicare proposes to re-evaluate the reimbursement of surgical services.

2015 New Coding Requirements For Modifier -59

The Centers for Medicare & Medicaid Services (CMS) new coding requirements related to modifier 59. This modifier is the most widely-used modifier and indicates a service that is separate and distinct from another service. CMS is establishing the following four new modifiers (referred to collectively as -X{EPSU} modifiers) to define specific subsets of the -59 modifier:

XE Separate Encounter: A service that is distinct because it occurred during a separate encounter XS Separate Structure: A service that is distinct because it was performed on a separate organ/structure XP Separate Practitioner: A service that is distinct because it was performed by a different practitioner XU Unusual Non-Overlapping Service: The use of a service that is distinct because it does not overlap usual components of the main service These modifiers are valid before National Edits go into effect on January 2015. At this time, CMS will accept either a -59 modifier or a more selective - X{EPSU} modifier; however, the use of the more selective modifiers is encouraged.

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